1. Antegrade Femoral Artery Access
A Primer to Percutaneous Endovascular intervention
Antegrade Femoral Artery Access
Nelson Lim Bernardo, MD Director, Peripheral Vascular Laboratory
Medstar Heart Institute at Washington Hospital Center
Washington, D.C.

2. Terumo Cardiovascular Systems Group
Nelson L. Bernardo, MD
Honoraria:
Abbott Vascular
Cook Group Incorporated
Cordis Corporation
Covidien
Medtronic, Inc.
Terumo Cardiovascular Systems Group

3. Faculty Disclosure
Abbott Vascular – Training Site
Cook Medical – Training Site
Cordis Endovascular – Training Site
Covidien/eV3 – Training Site
Medtronic – Training Site
No conflict of interest related to this presentation
Non-IFU use of devices will be discussed

4. Vascular Access
Proficiency in access of any vascular bed is of foremost importance
Cross-over femoral artery (retrograde)
Antegrade femoral artery
Retrograde SFA/popliteal/pedal artery
Axillary/brachial artery
Radial/ulnar artery

5. Vascular Access
Proficiency in access of any vascular bed is of foremost importance
Cross-over femoral artery (retrograde)
Antegrade femoral artery
Retrograde SFA/popliteal/pedal artery
Axillary/brachial artery
Radial/ulnar artery
NO Access = NO Intervention

6. Vascular Access for L.E. intervention
Retrograde - Cross-over femoral artery access
Most commonly used access to the lower extremity from the contralateral femoral artery
Familiar, easy & convenient (‘Comfort zone’)
Have limitations

7. Cross-over FA access: Limitations
AAA stent-graft

8. Cross-over FA access: Limitations
AAA stent-graft
Bilateral common iliac artery stents

9. Cross-over FA access: Limitations
AAA stent-graft
Bilateral common iliac artery stents
Aorto-bifemoral artery bypass; Fem-femoral bypass grafts
Steep iliac bifurcation
Non-compliant heavily Ca+2 ileo-femoral arteries

10. Cross-over FA access: Limitations
AAA stent-graft
Bilateral common iliac artery stents
Aorto-bifemoral artery bypass; Fem-femoral bypass grafts
Steep iliac bifurcation
Non-compliant heavily Ca+2 ileo-femoral arteries
 Impediments to successful cross-over

11. Cross-over FA access: Limitations
AAA stent-graft
Bilateral common iliac artery stents
Aorto-bifemoral artery bypass graft
Steep iliac bifurcation
Non-compliant heavily Ca+2 ileo-femoral arteries
Needed ‘support’ to cross femoral-popliteal/tibio- peroneal lesions & CTO
Limited balloon and device catheter ‘working’ length

12. Cross-over FA access: Limitations
AAA stent-graft
Bilateral common iliac artery stents
Aorto-bifemoral artery bypass graft
Steep iliac bifurcation
Non-compliant heavily Ca+2 ileo-femoral arteries
Needed ‘support’ to cross femoral-popliteal/tibio- peroneal lesions & CTO
Limited balloon and device catheter ‘working’ length
 Cross-over vascular access NOT ideal

13. Antegrade Femoral Artery Access
Antegrade access of common femoral artery with placement of sheath into the ipsilateral femoral or popliteal artery
Technical consideration:
Previous imaging study showing patent CFA and proximal to mid SFA segments - ‘landing’ zone
Ipsilateral
Femoral Artery
Antegrade
Approach

14. Antegrade Femoral Artery Access
Advantages:
Better ‘support’ & higher success to cross complex L.E. lesions/CTO
Can reach distal pedal lesions
Less contrast use
Novice operator:
Learning curve
Radiation exposure
Ipsilateral
Femoral Artery
Antegrade
Approach

15. Antegrade Femoral Artery Access
Technical considerations:
Previous imaging study showing patent CFA and proximal to mid SFA segments - ‘landing’ zone
‘Difficult’ to access in obese patients – ‘difficult’ hemostasis and risk for groin complication(s)
- NOT ideal for access

16. Antegrade Femoral Artery: Step-by-step
Work on the left, Image Intensifier on the right
Less radiation
‘Comfortable’ - Ergonomical

17. Antegrade Femoral Artery: Step-by-step
Work on the left, Image Intensifier on the right
Less radiation
‘Comfortable’ - Ergonomical
Access CFA using micropuncture needle
Duplex ultrasound guidance
Fluoro guidance - landmarks from ‘old’ angio

18. Common Femoral Artery Anatomy
Inguinal skin crease
(non-obese male)

19. Common Femoral Artery Anatomy
Ideal Needle
Entry Site

20. Antegrade CFA Access: Considerations
Approximately 3 cm of common femoral artery (CFA) lies between inguinal ligament and femoral bifurcation – segment to access with micropuncture needle
inguin

21. Antegrade Femoral Artery: Step-by-step
Access of CFA:
Too low - not enough room to access the SFA
Skin entry above the inguinal ligament (top of the femoral head)
Ideal Needle
Entry Site
inguin

22. Antegrade Femoral Artery: Step-by-step
Access of CFA:
Less acute, i.e. <45O angle, entry is usually required for smooth insertion of sheath and catheters.
Ideal Needle
Entry Site
inguin

23. Antegrade Femoral Artery: Step-by-step
Work on the left, Image Intensifier on the right
Less radiation
‘Comfortable’ - Ergonomical
Access CFA using micropuncture needle
Duplex ultrasound guidance
Fluoro guidance - landmarks from ‘old’ angio
Insert micropuncture sheath & do angio
Angio: Ipsilateral O angle
Ensure CFA ‘stick’ and access into SFA
Right SFA

24. Antegrade FA Access: “Wire” in DFA
Stick ‘too-low’ in the CFA
with guidewire into the deep femoral artery
Options:
‘repositioning’ of wire into SFA
Re-access higher in CFA
Use of SFA-’redirecting’ access device
CFA
DFA
SFA

25. Antegrade FA Access: SFA access device
Side hole on device allows redirecting the guidewire from the lumen of the terminal hole to the lumen of the side-hole

26. Antegrade FA Access: Use of SFA access device
Insert SFA access device over guidewire into the deep femoral artery
with guidewire into the deep femoral artery
CFA
DFA
SFA

27. Antegrade FA Access: Use of SFA access device
Reposition SFA access device with side-hole directed towards SFA
CFA
DFA
SFA

28. Antegrade FA Access: Use of SFA access device
Pull guidewire from the lumen of the terminal hole and advance through the side-hole into the lumen of the SFA
Pull out access device and advance sheath over guidewire into the SFA
CFA
DFA
SFA

29. Antegrade Femoral Artery: Step-by-step
Work on the left, Image Intensifier on the right
Less radiation
‘Comfortable’ - Ergonomical
Access CFA using micropuncture needle
Duplex ultrasound guidance
Fluoro guidance - landmarks from ‘old’ angio
Insert micropuncture sheath & do angio
Angio: Ipsilateral 30-50O angle
Ensure CFA ‘stick’ and access into SFA
Insert ‘long’ sheath
Use stiff guidewire, i.e. Supracore
Proceed with PEI
Popliteal
artery AT
TP trunk
Right BTK
Right Foot

30. POBA of dorsalis pedis A.
Antegrade Femoral Artery: Step-by-step
Work on the left, Image Intensifier on the right
Less radiation
‘Comfortable’ - Ergonomical
Access CFA using micropuncture needle
Duplex ultrasound guidance
Fluoro guidance - landmarks from ‘old’ angio
Insert micropuncture sheath & do angio
Angio: Ipsilateral 30-50O angle
Ensure CFA ‘stick’ and access into SFA
Insert ‘long’ sheath
Use stiff guidewire, i.e. Supracore
Proceed with PEI - Recanalize AT CTO
POBA of dorsalis pedis A.

31. MP: Successful Recanalization for CLI
Post-PEI – Right BTK
Post-PEI – Right foot

32. Antegrade Femoral Artery: Step-by-step
Hemostasis
Manual compression
Remember: Arteriotomy site is ‘distal’ or ‘lower’ to the skin entry site
Vascular closure device

33. Antegrade Femoral Artery Access
Successful vascular access with good hemostasis are key to a successful percutaneous endovascular intervention.
Know femoral/vascular anatomy and ‘nuances’ of antegrade femoral artery access. This technique is an important armamentarium in a vascular interventionalist’s toolbox.

34. A Primer to Percutaneous Endovascular intervention
Thank You